Healthcare Provider Details

I. General information

NPI: 1558414953
Provider Name (Legal Business Name): BLACKSTONE MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6780 INDIANA AVE STE 170
RIVERSIDE CA
92506-4284
US

IV. Provider business mailing address

6780 INDIANA AVE STE 170
RIVERSIDE CA
92506-4284
US

V. Phone/Fax

Practice location:
  • Phone: 951-680-0909
  • Fax: 951-680-0906
Mailing address:
  • Phone: 951-680-0909
  • Fax: 951-680-0906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA64941
License Number StateCA

VIII. Authorized Official

Name: AHMAD M. ALTURJUMAN
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D., F.A.C.C.
Phone: 951-680-0909